Co-operation in emergency care between Helsinki University Central Hospital and City of Helsinki Liisa-Maria Voipio-Pulkki MD, PhD Chief Physician, Emergency Care Dept of Medicine, HUCH (Senior Medical Adviser, The Association of Finnish Local and Regional Authorities, 2-12/04)

Does EMS matter? in Finnish university hospitals in 2002, emergency / acute care consumed –20-30% of laboratory and imaging capacity –44% of ward capacity (also in psychiatry) –27% of surgical capacity (in Meilahti 50%) 40% of hospital costs

Strategic questions in EMS Emergency/acute services have become the mainstream of health care delivery –why? is it good or bad for the outcome? –gatekeeper, outreach, crossroads or what? –thinner EBM tradition –heavy conflicts of interest common –secondary effects of political decision making Based on patient transfer or transfer of information, professionals & responsibility? Role in regional clinical pathways?

Helsinki in the 2000´s: Increasing volumes, fluctuation, overcrowding, unclear resource allocation # visits and hospitalized patients in 2003 –internal medicine (51%) –surgery (56%) –neurology7 500(39%) situation in primary care –20-30% of GP visits – no defined strategy to centralize or decentralize acute primary care –innovative models needed, partic geriatric pts

Who are our ”customers”? What is our role in providing service to them? How good are we? Helsinki University Central Hospital EMS

Customers: population basis HUCH Helsinki and Uusimaa Kymenlaakson Etelä-Karjala Total

Fragmentation of EMS in Helsinki out-of-hospital EMS acute care by GP´s (public / private) centralized primary care (4PM-) joint minor trauma and pediatric services small ER´s by some clinics separate orthopedics & trauma center joint ER for medicine, neurology, surgery separate psychiatry services

General practice and specialized care – simplified ”24/7 one door principle” Minor trauma 24 h / d Hospital ER basic level 24 h / d Centralized acute primary care 4-10 P.M. Specialized care 24 h / d

Predicted volume of university and city (hospital) emergency services in 2005 Visits per year Primary level Intermediate level Specialized level (excl trauma center) Total

How to direct patient flows? common planning (all hospitals, EMS) with semiannual feedback consultations described in writing for all partners based on needs, no organizational borders global acceptance for present application inform all staff groups AND the public provide multiple tools for implementation surveys, audits, automated follow-up set compliance goals (max 75-80%!)

Variable case load in specialized care– how to predict and adapt (or perhaps even more than that…) structured statistics, buffers, simulations…

Electronic patient chart and hospital administration system: hourly to monthly reporting, process analysis

Tailored reports to all levels of staff & management,derived from the same database

How to control outcome? (whose outcome..with which indicators..so what?)

From reactive to proactive leadership in acute care explicit local agreements appropriate clinical pathways & in-house processes (a lot of work!) structured treatment protocols decision support toolkits realistic resources (bechmarking?) measure, inform, audit communication, feedback mechanisms, error surveillance and prevention

Academic Emergency Medicine? (academic = special hospital care?)

Common strategy in EMS: is there more than the visit numbers, walls and technology (power, money and fame…) ? demand evidence based practices and knowledge based political decision making systems thinking: move from power play to cooperation and win-win treasure team work and empower devoted staff, but question traditions HBU: EMS as a societal safety net – who´s health care is it anyway?